Endoscopic Cerebrospinal Fluid Research Articles

Peri-operative management of endoscopic endonasal cerebrospinal fluid leak repair: an international survey.

Peri-operative management of nasal cerebrospinal fluid (CSF) leaks is not consensual due to limited evidence. The main aim of this study was to identify key factors in peri-operative management of endoscopic endonasal CSF leak repair among international experts. A 60-item survey questionnaire collected opinions of members of international learned societies of ENT surgeons and neurosurgeons on nasal packing, post-operative instructions, antibiotic prophylaxis, and CSF volume depletion. The survey had 153 respondents (124 otorhinolaryngologists and 29 neurosurgeons). A resting position was recommended by 85% (130/151) of respondents for extended CSF leak of the anterior skull base, mainly in Fowler's position (72% (110/153)). Nasal packing was used by 85% (130/153) of respondents; 33.3% (51/153) used it to stabilize the reconstruction, and 22.2% (34/153) to prevent bleeding. It was usually removed after 48h in 44.4% of cases (68/153). CSF depletion was considered by 47.1% (72/153) of respondents in case of CSF leak recurrence and by 34.6% (53/153) in cases of increased intracranial pressure. All respondents gave specific postoperative instructions to patients including driving, running, swimming, diving restrictions and flighting restrictions. In subgroup analysis, ENT surgeons more often recommended a resting position than neurosurgeons (71% vs. 37.9% ; p = 0.0008) and prescribed more antibiotics (82.3% vs. 21.4% ; p < 0.0001). Although postoperative management after CSF closure remains challenging and not codified, this international survey revealed some points of consensus concerning resting position and restriction of post-operative activities. Prospective clinical studies must be undertaken to evaluate their efficiency.

Endoscopic Repair of Anterior Skull Base Cerebrospinal Fluid Leaks is Successful in Frail Patients.

Surgical frailty estimates a patient's ability to withstand the physiologic stress of an intervention. There is limited data regarding the impact of frailty on endoscopic cerebrospinal fluid (CSF) leak repair. Patients undergoing CSF leak repair at two tertiary academic skull base programs were retrospectively reviewed. Demographic, treatment, and postoperative outcomes data were recorded. Frailty was calculated using validated indices, including the American Society of Anesthesiologists (ASA) classification, Charlson Comorbidity Index (CCI), and the Modified 5-Item Frailty Index (mFI-5). Outcomes included 30-day medical and surgical complications and readmission. A total of 185 patients were included with 128 (69.2%) female patients and average age of 54 ± 14 years. The average body mass index was 34.6 ± 8.5. The most common identified etiology was idiopathic intracranial hypertension (IIH) in 64 patients (34.6%). A total of 125 patients (68%) underwent perioperative lumbar drain placement (primarily to measure intracranial pressures and diagnose IIH). Most patients were ASA class 3 (48.6%) with mean CCI 2.14 ± 2.23 and mFI-5 0.97 ± 0.90. Three patients had postoperative CSF leaks, with an overall repair success rate of 98.4%. There was no association between increased frailty and 30-day medical outcomes, surgical outcomes, or readmission (all p > 0.05). Endoscopic CSF leak repair in a frail population, including lumbar drain placement and bed rest, was not associated with an increased rate of complications. Previous data suggests increased complications in open craniotomy procedures in patients with significant comorbidities. This study suggests that the endoscopic approach to CSF leak repair is well tolerated in the frail population. IV Laryngoscope, 134:2713-2717, 2024.

Cerebrospinal fluid leakage due to dural thinning after endoscopic pituitary tumor resection.

Sellar reconstruction is important for preventing cerebrospinal fluid (CSF) leakage after transsphenoidal pituitary surgery. This report describes how, despite standard sellar reconstruction, CSF exudation resulted from dural thinning at the anterior skull base, outside the intrasellar area manipulated during pituitary tumor resection. A 76-year-old man underwent endoscopic transsphenoidal surgery for a pituitary tumor extending toward the anterior skull base. After opening the sellar floor, intractable bleeding from the anterior intercavernous sinus occurred during bone removal at the anterior skull base. Pseudocapsule-based extracapsular resection was completed after stopping the bleeding. On the 10th postoperative day, the patient developed CSF rhinorrhea complicated by marked pneumocephalus, and emergency endoscopic repair of the CSF leak was performed. CSF leakage originated from the thinned dura at the anterior skull base located outside the intrasellar area manipulated during tumor resection. The thinned dural area at the anterior skull base coincided with the site of intractable bleeding of the anterior intercavernous sinus during bone removal in tumor resection. The thinned anterior skull base dura was covered with fascia, overlaid with fat, and closed with the nasoseptal flap. Endoscopic CSF leak repair was successful. Severe damage to the anterior intercavernous sinus can cause extensive exposure of the single-layered inner meningeal dura, where thinning might result in CSF exudation. Therefore, use of autologous tissues to cover and reinforce the severely damaged area of the anterior intercavernous sinus might help prevent postoperative CSF exudation.

Safety and Feasibility of Steroid-Eluting Stent as a Bolster in Endoscopic Anterior Skull Base Reconstruction.

With a rising incidence of cerebrospinal fluid (CSF) leaks, endoscopic endonasal CSF leak repair is increasingly performed. Current approaches utilize a variety of materials including free mucosal grafts and vascularized flaps, but post-op leaks continue to be reported. Steroid-eluting bioabsorbable stents (SES) are used during functional endoscopic sinus surgery for chronic rhinosinusitis to reduce inflammation and scarring while maintaining patency of sinus ostia. The aim of this study is to assess the feasibility of SES as a graft/flap bolster for endoscopic endonasal CSF leak repair. This is a retrospective review of patients undergoing endoscopic endonasal CSF leak repair with SES placed as part of the bolster technique at a tertiary care center between January 2019 and May 2022. Age, sex, BMI, comorbid idiopathic intracranial hypertension, pathology, location of CSF leak, intraoperative CSF leak flow, reconstruction type, and presence of post-op CSF leak were recorded. Twelve patients (mean age 52, median BMI 30.9, 58% female) had SES placement as part of the bolster technique. The most common pathology was meningoencephalocele (75%). Reconstruction was performed with either a free mucosal graft (6), or a flap (6). No post-op CSF leaks occurred at a reconstruction site with a stent, and no known complications were reported. All sinusotomies were patent at the last follow-up visit. SES placement as an adjunct to graft and/or flap bolster appears to be safe and feasible during anterior skull base reconstruction and CSF leak repair providing longer term structural support and preserving sinus drainage patency.

Cerebrospinal fluid rhinorrhea: a novel approach

Background: This study aimed to describe the use of nasal endoscopic technique in the management of cerebrospinal fluid (CSF) rhinorrhea repair. Over the last decade, endoscopic surgery has established itself as the most widely used technique for the repair of CSF leak. Methods: 20 patients diagnosed with CSF rhinorrhea undergoing endoscopic CSF rhinorrhea repair were included in this study. To confirm the diagnosis beta-2 transferrin test was done. Accurate localization of site of lesion using CT cisternography was done. Results: Spontaneous onset of CSF rhinnorhea was noted in 75% of patients. The most common cause of CSF rhinorrhea in our study was spontaneous and the second most common cause was post traumatic. Almost 45% of patients presented with headache as primary complaint, 30% with only CSF leak, 20% with nasal obstruction and rest 5% with hyposmia. Conclusions: Multilayered closure of the dural defect was done. It can be concluded that middle aged people presented as CSF rhinorrhea with female predominance and there was high success rate of endoscopic CSF rhinorrhea repair with low morbidity.

Spontaneous rhinorrhea: a possible concealing initial symptom of ecchordosis physaliphora. Illustrative case.

Spontaneous rhinorrhea may be the initial manifestation of ecchordosis physaliphora (EP). There are currently 47 published cases of symptomatic EP, with spontaneous rhinorrhea being one of the most prevalent symptoms. The authors report 1 case as a cause of cerebrospinal fluid (CSF) fistula. A 46-year-old woman presented to the authors' clinic with meningitis secondary to nasal CSF leakage. The computed tomography (CT) scan indicated an imperceptibly thin/dehiscent focus along the posterior wall of the sphenoid air cell's midline. A tumor was identified during endoscopic endonasal CSF repair surgery. EP was diagnosed in the frozen and final pathology. EP should be considered as a potential cause of spontaneous rhinorrhea. This initial clinical manifestation accounts for 35% of symptomatic EP cases. The prepontine and posterior sphenoid sinus wall appear to be the locations with the highest susceptibility. Surgical therapy of the fistula without excision of the lesion may result in insufficient issue resolution and recurrence.

Symptom: Runny Nose Six Years After Acoustic Neuroma Surgery

Symptom: Runny Nose Six Years After Acoustic Neuroma Surgery

Management of Traumatic and Non-Traumatic Cerebrospinal Fluid Rhinorrhea-Experience from Three Southeast Asian Countries.

Cerebrospinal fluid (CSF) rhinorrhea requires proper management to avoid disastrous consequences. The objectives of this study were to ascertain the patient characteristics, etiologies, sites of defect, skull base configurations, methods of investigation, and management outcomes of CSF rhinorrhea. A retrospective study was performed over 4 years involving three surgeons from Malaysia, Singapore, and Thailand. Hospital records were reviewed to determine the patients' characteristics, the causes and sites of leaks, methods of investigation, skull base configurations, choices of treatment, and outcomes. A total of 15 cases (7 traumatic and 8 non-traumatic) were included. Imaging was performed in all cases. The most common site of leakage was the cribriform plate (9/15 cases). The mean ± SD of the Keros heights were 4.43 ± 1.66 (right) and 4.21 ± 1.76 mm (left). Type II Keros was the most common (60%). The mean ± SD angles of the cribriform plate slope were 51.91 ± 13.43 degrees (right) and 63.54 ± 12.64 degrees (left). A class II Gera configuration was the most common (80%). All except two patients were treated with endonasal endoscopic surgical repair, with a success rate of 92.3%. A multilayered repair technique was used in all patients except one. The mean ± SD postoperative hospital stay was 9.07 ± 6.17 days. Non-traumatic CSF rhinorrhea outnumbered traumatic CSF rhinorrhea, with the most common site of leak at the cribriform plate. Imaging plays an important role in investigation, and Gera classification appears to be better than Keros classification for evaluating risk. Both conservative and surgical repairs are practiced with successful outcomes. Endonasal endoscopic CSF leak repair is the mainstay treatment.

Endoscopic cerebrospinal fluid leak repair combined with thecoperitoneal shunting for spontaneous cerebrospinal fluid rhinorrhea: MERF experience

&lt;p&gt;&lt;strong&gt;Background:&lt;/strong&gt; Spontaneous cerebrospinal fluid (CSF) rhinorrhoea is encountered as a diagnosis of exclusion in clinical practice once all other aetiologies have been meticulously ruled out and can mostly present from preformed pathways due to benign intracranial hypertension (BIH) over time. Such leaks need to be clearly located for planning appropriate repair along with adequate control of CSF pressure to avoid recurrence. Thus, the aim of our study was to review the efficacy and outcomes of a combined endoscopic multilayered repair along with simultaneous theco-peritoneal shunting (TPS) for patients with spontaneous CSF rhinorrhoea in the background of BIH.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Methods:&lt;/strong&gt; Retrospective observational study analyzing the clinical presentations, surgical techniques and the immediate / long term outcomes of this combined approach.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Results: &lt;/strong&gt;The&lt;strong&gt; &lt;/strong&gt;46 patients who had endoscopic CSF repair with TPS done between 2008-2019 were reviewed. The mean opening CSF pressure in these cases were &amp;gt;25 cm H&lt;sub&gt;2&lt;/sub&gt;O. The commonest site of leak was from cribriform plate followed by fovea ethmoidalis. Multilayered closure was done with autologous grafts along with TPS simultaneously. The 92% were successful, 6% had shunt problems needing revision shunts and 2% also needed revision endoscopic repair. &lt;/p&gt;&lt;p&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; Overall outcomes shows that the combined approach was safe and effective in arresting the CSF leak in 98% patients. Therefore, the rationale for a combined approach for the management of spontaneous CSF leaks in the background of BIH stands proven based on our Institutional experience.&lt;/p&gt;

A Comparative Analysis of Transcranial and Endoscopic Repair for Traumatic CSF Rhinorrhea.

Surgical treatment of anterior cranial base traumatic cerebrospinal fluid (CSF) rhinorrhea is challenging and is fraught with complications. Whether a person should be offered open craniotomy or endoscopic endonasal repair is a dilemma faced by most surgeons. This study is one of the few to directly compare the two forms of management. Data were collected from two groups of 15 patients each who underwent transcranial CSF leak repair and endoscopic endonasal CSF leak repair in a tertiary care hospital over a 3-year period. Information including demographics, recurrence rates, complications, and hospital and intensive care unit (ICU) stay was recorded and analyzed. Outcome was assessed up to 6 months. Recurrence was seen in 9/30 patients, 6 in the transcranial group and 3 in the endoscopic group. Hospital stay was longer than 1 week in all the transcranially operated patients and only in 73% of the endoscopically operated patients (p = 0.439) although ICU stay was reduced in the endoscopic group (p = 0.066). Complications were more common with transcranial repair (seven of eight patients who underwent transcranial repair, p = 0.035) with anosmia being the most common (33.3%, p = 0.042). The transcranial open repair is a reasonable choice especially for leaks that occur through the frontal sinus and extend backward into the frontoethmoidal region. However, this approach has the drawbacks of greater number of complications, higher recurrence rate, and longer ICU and overall hospital stay. The endoscopic endonasal repair enjoys a lower morbidity profile although it may not be an adequate treatment for leaks that are placed far laterally in the frontal sinus.

Outcomes of transnasal endoscopic repair of cerebrospinal fluid leaks: a prospective cohort study

BackgroundAlthough cerebrospinal fluid (CSF) leak repair of the anterior and middle skull base defect by endonasal endoscopic surgery (EES) presents one of the more difficult challenges, it has shown high success rates with less morbidity. Our objective is to evaluate the outcomes of transnasal endoscopic repair of CSF leak regarding success rate, impact on olfaction, and sinonasal function.MethodsA prospective cohort study was conducted to evaluate the CSF leak repair outcomes related to the site, size of the defect, surgical techniques, and the materials that been used through Smell Identification Test (SIT), 22-item Sino-Nasal Outcome Test (SNOT-22), Perioperative Sinus Endoscopy score (POSE), and Lund-MacKay Scoring (LM) of CT scan.ResultsTwenty-one patients were enrolled in the study; 12 out of 21 were females with a higher prevalence of traumatic causes of 61.9%. Different techniques and materials were used for the repair with a success rate recorded at 90.5% after the first closure attempt. The mean standard deviation (SD) scores postoperatively (after 6 months) was markedly decreased in SNOT 22 with mean (SD) 5.55 ± 3.6, slightly increase in POSE (mean ± SD = 0.43 ± 0.6), and slightly decrease in SIT (mean ± SD =10.31 ± 4.7) and LM (mean ± SD = 0.57 ± 0.7).ConclusionTransnasal endoscopic CSF leak repair is an effective technique for skull base defect closure with a high success rate and no valuable morbidity to sinonasal function other than mild hyposmia in patients where nasoseptal (NSF) and septal flap have been used.Trial registrationThe study was approved by the institutional review board and ethics committee of (The Arab Board of Health Specializations) with order no. (453) on 1April 2018.

Endoscopic Repair of Cerebrospinal Fluid (CSF) Rhinorrhea with Multilayer Grafts

Introduction: Endoscopic repair of Cerebrospinal fluid (CSF) rhinorrhea has been the most popular and the most accepted among the Otorhinolaryngologists. The advancement in the endoscopes enable surgeons to manage cerebrospinal fluid rhinorrhea adequately with good result.&#x0D; Objective: The aim of this study was to evaluate the outcome of endoscopic CSF rhinorrhea repair with multilayer grafts. Outcome was identified in terms of postoperative complications like infection (mainly meningitis), nasal bleeding, graft failure and CSF leak, revision surgery.&#x0D; Methodology: A retrospective prospective study was conducted in 21 patients who had undergone endoscopic CSF rhinorrhea repair with use of multilayer grafts in a period of January 2016 to December 2018 in Department of ENT and Head and Neck Surgery in MAA ENT HOSPITAL, HYDERABAD, INDIA. All the patients were diagnosed according to history, clinical examination, diagnostic nasal endoscopy, CSF fluid analysis and radiological investigation. The materials used for the repair of CSF rhinorrhea were surgicel, temporalis fascia, conchal chondroperichrondrium, middle turbinate free mucoperiosteum graft, thigh fat and fascia lata. The follow up period of patients range from 14-44 months. The outcome of endoscopic CSF repair with use of multilayer grafts was evaluated by electronic records regarding recurrence of CSF rhinorrhea post-surgery, hospital admission, revision surgery and digital record of rigid endoscopic findings for the status of graft uptake and CSF leak.&#x0D; Results: In all patients, CSF leak was successfully repaired with use of multilayer grafts in first attempt without any complication. There was female predominance with male to female ratio of 1:6.The mean age of presentation was 43.09years. All 21 patients were presented with spontaneous CSF leak with unknown cause. In 21 patients only one patient presented with bilateral cerebrospinal fluid leak. Cribri form plate was the commonest site of defect in which defect medial to middle turbinate was the commonest followed by ethmoid roof and lateral wall of sphenoid. None of the patients developed meningitis after surgery. None of the patients required lumbar drain. None of the patients presented with cerebrospinal fluid rhinorrhea postoperatively.&#x0D; Conclusions: Endoscopic repair of Cerebrospinal fluid rhinorrhea with the use of multilayer grafts is the safer and effective method with good outcome.

The Endonasal Endoscopic Management of Cerebrospinal Fluid Rhinorrhea.

IntroductionCerebrospinal fluid (CSF) rhinorrhea is the result of a bony defect at the skull base with disruption of the arachnoid, dura mater, and sinonasal mucosa that leads to an active CSF leak and flow of clear fluid from the nose. The endoscopic repair of CSF leaks and skull defects have been used by an increasing number of surgeons and is the standard of care for repairing CSF leaks.Materials and methodsWe conducted a retrospective study of all cases of CSF leaks managed via the endonasal endoscopic approach from 2010 to 2020 at a tertiary referral hospital of King Fahad Specialist Hospital, Dammam (KFSH-D).ResultsOver 10 years, 61 procedures were performed on a total of 56 patients (average age, 39.9 years) with 26 spontaneous CSF leaks and 30 traumatic CSF leaks. The leak sites were frontal bone in 14% of the cases, the roof of the ethmoid in 25%, the cribriform plate of ethmoid in 39%, and the walls of sphenoid sinus in 21%; multiple site defects were found in eight patients. The defect was localized by high-resolution computed tomography (CT) of the paranasal sinuses and skull base and magnetic resonance imaging (MRI) in all patients. CT cisternography, intrathecal fluorescein injection, and topical application of fluorescein dye were used in patients as required. A combination of free grafts and flaps materials were used in most patients. A middle and inferior turbinate graft was used in 12 patients, a septal cartilage graft in 18 patients, and a pedicled nasoseptal flap in 12 patients. The success rate was 92% after the first closure attempt. A recurrence of CSF leaks was observed in four patients. The mean hospitalization time was 6.5 days. The postoperative follow-up period ranged from one year to 10 years with a mean postoperative follow-up time of three years.ConclusionsThe endonasal endoscopic approach is the current standard of care for repairing most CSF leaks and skull base defects. We have had an excellent experience with endonasal endoscopic CSF leak repair, with high success rates and low morbidity. Our results support the effectiveness and safety of this technique and should encourage otolaryngologists to apply the procedure in cases of CSF leak.

Hydrocephalus Associated with Posterior Fossa Tumors: How to Manage Effectively?

Hydrocephalus associated with posterior fossa tumor (PFT) is a common neurosurgical problem, the management of which is still controversial. To provide an overview of the advantages and limitations of different management strategies for hydrocephalus associated with PFT both before and after resection of these tumors. Structured review of the literature on the management of hydrocephalus in PFT both in children and adults. The incidence of hydrocephalus associated with PFT at the time of presentation is more in children (70-90%) than adults (10-21%). This difference is maintained for hydrocephalus after the resection of PFT (~30% for children and 1.2-6.9% for adults). Preresection hydrocephalus is obstructive while emerging evidence in the literature suggests that postresection hydrocephalus may have a communicating component. The treatment of preresection hydrocephalus associated with PFT has undergone a paradigm shift in the past two decades. Preoperative Cerebrospinal Fluid (CSF) diversion is less commonly used except when required by the clinical condition of the patient. Preresection hydrocephalus may be treated by steroid use and early tumor removal, perioperative use of external ventricular drainage, or endoscopic third ventriculostomy in selected patients. Various prediction scales are available to assess the risk of postresection hydrocephalus in PFT. Certain histological tumor types and molecular phenotypes of PFT are more commonly associated with hydrocephalus. CSF diversion through endoscopic third ventriculostomy or ventriculoperitoneal shunts remains the management strategies for postresection hydrocephalus. The failure rates and the time-to-failure of both endoscopic third ventriculostomy and CSF shunts in PFT are variable and surgeons should be aware of these while taking management decisions. Hydrocephalus associated with PFT affects the quality of life of patients with such lesions. Routine preoperative CSF diversion is not necessary for the vast majority of patients with posterior fossa tumor-related hydrocephalus. A high index of suspicion and aggressive surveillance is required for the early identification and appropriate management of postresection hydrocephalus. Future studies are needed to address several unanswered questions pertaining to the management of this condition.

Use of Acetazolamide in the Postoperative Care of Endoscopic Cerebrospinal Fluid Leak Closure

Spontaneous cerebrospinal fluid (CSF) leaks are defined as leaks without identifiable etiology, often presenting as spontaneous rhinorrhea. This is thought to be a variant of idiopathic intracranial hypertension (IIH). Spontaneous CSF leak closure often requires surgery, which has proven to be less successful than their non-spontaneous counterparts. There is growing evidence that active intracranial pressure (ICP) management in the postoperative care can improve success rates. We aim to give an update about the current use of acetazolamide in the postoperative care of spontaneous CSF leak closure.

Management of coexistent sinonasal pathology in patients undergoing endoscopic cerebrospinal fluid rhinorrhea repair

IntroductionPatients who undergo endoscopic cerebrospinal fluid rhinorrhea repair may occasionally present with coexistent sinonasal pathology which may or may not need to be addressed prior to surgical repair. Some patients may develop new onset nasal morbidity related to endoscopic repair. ObjectiveTo study the prevalence and management of additional sinonasal pathology in patients who undergo endoscopic repair of cerebrospinal fluid rhinorrhea MethodsA retrospective review of patients who underwent endoscopic cerebrospinal fluid leak repair was conducted to note the presence of coexistent sinonasal morbidity preoperatively and in the followup period. ResultsOf a total of 153 patients who underwent endoscopic closure of cerebrospinal fluid leak, 97 (63.4%) were female and 56 (36.6%) males. Most patients (90.2%) were aged between 21 and 60 years, with a mean of 40.8 years. Sixty-four patients (41.8%) were found to have coexistent sinonasal morbidity preoperatively, the commonest being symptomatic deviated nasal septum (17.6%), chronic rhinosinusitis without polyps (11.1%) and chronic rhinosinusitis with polyps (3.3%). Rare instances of septal hemangioma (0.7%) and inverting papilloma (0.7%) were also seen. Postoperatively, there was cessation of cerebrospinal fluid rhinorrhea in 96.7% which rose to 100% after revision surgery in those with recurrence. Resolution of coexistent sinonasal pathology occurred in all patients with followup ranging from 10 to 192 months. New onset sinonasal morbidity which developed postoperatively included synechiae between middle turbinate and lateral nasal wall (5.9%) and sinonasal polyposis (1.3%). ConclusionPatients who undergo endoscopic cerebrospinal fluid leak repair may have coexistent sinonasal pathology which needs to be addressed prior to or along with repair of the dural defect. New onset sinonasal morbidity, which may arise in a few patients postoperatively, may require additional treatment. A protocol for the management of coexistent sinonasal conditions ensures a successful outcome.

Cribriform CSF Leak: Endoscopic Surgical Repair Using Free Septal Mucosal Graft Without Postoperative Nasal Packs.

Cribriform plate is the commonest site of Cerebrospinal fluid (CSF) leak, its fragility and juxtaposition of arachnoid's investment to the bone, where the olfactory nerve pierces the skull, is a vulnerable site for CSF leak. Endoscopic transnasal approach has been the main stay for CSF leak repair over the past 2 decades. The technique and surgical steps of Endoscopic Surgical Repair of Cribriform CSF Leak using Free Septal Mucosal Graft without Postoperative Nasal packs are presented. Transnasal endoscopic CSF leak repair under General anesthesia with free mucosal graft, the critical steps include visualize the site of leak, lateralisation of middle turbinate, defect site cauterised with bipolar cautery. Free mucosal from contralateral side of the septum was placed as overlay technique. Graft stabilised with surgicel after ensuring adequate contact between the graft and the defect site. If the defect site is large then fat harvested from thigh is used as bath plug the defect, then free mucosal graft is kept supported by surgicel. Finally the middle turbinate was medialized and sutured with 3 0' Vicryl with nasal septum to support the graft and also to stabilize the middle turbinate as a quilting stich. No fibrin glue was used in our case series. No nasal packing was done. Patients discharged on 2nd or 3rd postoperative day. This technique provides consistent good results reduced operating time of 40min, no post-operative morbidity, early mobilisation, with 100% success rate and with added advantage of no nasal packing, patient can easily breathing through the nose postoperatively & no recurrence on long follow up.

Delayed Cerebrospinal Fluid Leakage After Treatment of Skull Base Tumors: Case Series of 9 Patients

Cerebrospinal fluid (CSF) leaks usually happen in the early postoperative period. However, delayed CSF leak can happen several years after treatment. The purpose of this study was to review the characteristics and clinical course of delayed CSF leak after treating skull base tumors. We treated 9 patients with delayed CSF leak (occurring at least 3 months after treatment) between December 2015 and February 2018. Clinical data including initial treatment modality for skull base tumor, time between treatment and CSF rhinorrhea, and the result of endoscopic CSF repair were evaluated by retrospective chart review. Nine patients with delayed CSF leak were evaluated. The mean age was 42.3 ± 5.2 (mean ± SD) years. Six patients with pituitary adenomas, 1 with a Rathke cleft cyst, 1 with a meningioma, and 1 with an osteosarcoma were enrolled. Seven patients (78%) received radiation, and the mean radiation dose was 55.7 ± 2.6 Gy. The median time between the end of treatment for the skull base tumor and CSF rhinorrhea was 137.0 (interquartile range 24-145) months. Seven patients (78%) had meningitis at the time of operation. CSF rhinorrhea was treated with endoscopic reconstruction using a multilayer technique. Meningitis was improved without neurologic sequelae after reconstruction and antibiotic therapy. One patient had recurrence of CSF leak. Patients with delayed CSF leak are more likely to have a history of radiation and to present with meningitis at diagnosis. Therefore, CSF rhinorrhea should always be suspected, even several years after treatment, if early symptoms of CSF leak develop in patients with a history of skull base tumor.

Cost Effectiveness of Dural Sealants in Endoscopic Cerebrospinal Fluid Leak Repair

Cost Effectiveness of Dural Sealants in Endoscopic Cerebrospinal Fluid Leak Repair

Endoscopic Management of Intraventricular Neurocysticercosis.

To evaluate the technique and outcome of endoscopic management of intraventricular neurocysticercosis (NCC). We retrospectively analysed the records of 30 consecutive patients of intraventricular (intra-third and fourth ventricle) NCC who underwent endoscopic management. The clinical profiles of the patients were evaluated which included age, symptoms and signs. Transcranial endoscopy was performed through a frontal burr hole using a Gaab Universal Endoscope system with rigid 0° and 30° telescope for endoscopic third ventriculostomy and removal of the cyst was described. The mean follow-up period was 22.6 months. In 86.67% (26/30) patients we are able to visualize/excise/decompress the cyst. We were able to successfully excise all the third ventricular cysts (16/16) and in 66.67% (8/12) of the fourth ventricular cysts. In 90% (27/30) patients we were able to successfully divert the CSF flow and achieve long-term shunt free period. We found that endoscopic cerebrospinal fluid (CSF) diversion in cases of intraventricular NCC is feasible and associated with high success rate. Endoscopic CSF diversion in NCC related hydrocephalus usually produces a long-term cure.